FM-BINUS-AP-FBK-20/V2R4

SURAT PERMOHONAN PENARIKAN DANA (FUNDS

WITHDRAWAL REQUEST LETTER)

No.urut
Yth. (To) 588
Layanan Keuangan Mahasiswa (Student Financial Services)
Di Jakarta

Dengan hormat, (Dear Sir or Madam),

Saya calon Mahasiswa dengan identitas (Hereby I declare the identity mentioned):
No. Pendaftaran/NIM/Grade (No. Registration/ID Number/Grade) : 2702359774
Nama (Name) : Teuku Mohamad Gennaro Aldi
Alamat (Address) : Jalan Haji Mandor Salim No.9 Kembangan,Srengseng Jakarta Barat
Telepon/ HP (Phone/ Mobile Number) : 081319992313
Program (Program) : S1 Sistem Informasi
Ingin menarik dana yang telah disetor ke Universitas Bina Nusantara karena saya:
(Would request to withdraw the funds that have been deposited to BINUS UNIVERSITY under the following conditions)
 Diterima di PTN (Accepted in the State University)  Tidak lulus SMA/Sederajat (Not Graduated from Senior High School)

Diisi bila diterima di PTN/ tidak lulus SMA/Sederajat (Filled if accepted in the State University/not graduated from Senior High School)
Nama PTN atau Nama SMA/Sederajat (State Univ. Name or Senior High School Name) : Universitas Brawijaya
Jurusan PTN/ Jenjang Studi (State Univ. Major/ Study level) : Manajemen
Alamat (Address) : Jl. Veteran, Ketawanggede, Kec. Lowokwaru, Kota Malang, Jawa Timur 65145

Adapun rincian dana tersebut berasal dari (The detail of the funds derived from):
❑ Pembayaran Biaya Kuliah (Payment of College Fee) Rp. 22.800.000,00 ❑ Pembayaran Laboratorium (Payment of Laboratory Fee) Rp. 2.850.000,00 ❑ Pembayaran
DP3 (Payment of Contribution Fee) Rp. 41.000.000,00
❑ Pembayaran Seragam (Payment of Uniform Fee) Rp. ……………………….
❑ Pembayaran Peralatan (Payment of Equipment Fee) Rp. 9.500.000,00+
Jumlah (Total) Rp. 76.150.000,00
Biaya Administrasi (Administration Fee) Rp. 5.000.000,00_
Total yang dikembalikan (Total Refund) RP. 71.150.000,00

Untuk melengkapi surat permohonan ini, saya lampirkan (To complete this request form, I am attaching):
 Jika calon mahasiswa diterima sekaligus telah melakukan proses Daftar Ulang di Perguruan Tinggi Negeri (PTN) di bawah Kementerian Pendidikan, Kebudayaan,
Riset, dan Teknologi Republik Indonesia jenjang Strata 1 (S1) kecuali Universitas Terbuka dan PTN yang diselenggarakan oleh kementerian lainnya (If accepted and
registered as a student in the State University under the Ministry of Education, Culture, Research and Technology of the Republic of Indonesia from the Undergraduate
Level, except for Open University and State University under the other Ministry):
❑ Fotokopi bukti keterangan lulus ujian PTN (asli harus ditunjukkan). (Photocopy of passed exam receipt from the State University (original copy is mandatory)).
❑ Fotokopi bukti pembayaran biaya kuliah di PTN (asli harus ditunjukkan) (Photocopy of payment for college fee receipt from the State University (original copy is
mandatory)).
❑ Fotokopi bukti penerimaan pendaftaran ulang atau Kartu Mahasiswa di PTN atau jadwal orientasi / kuliah (asli harus ditunjukkan). (Photocopy of re-registration
acceptance or Student Card or orientation/class schedule from the State University (original copy is mandatory)).
❑ Fotokopi cover buku tabungan orang tua calon mahasiswa. (Photocopy of the bankbook cover of the prospective student’s parent).
❑ Paket Mahasiswa Baru UNIVERSITAS BINA NUSANTARA yang telah diambil (Jaket Almamater, Jas Laboratorium, Binusian Flazz Card, Kartu Briefing, dll)
(New Student’s BINUS UNIVERSITY Package that has been taken (Alma mater Jacket, Lab coat, Binusian Card Flazz, Briefing Card, etc)
❑ Jika penerima dana adalah pihak diluar orang tua calon mahasiswa, maka wajib melampirkan surat kuasa diatas materai, fotokopi KTP penerima kuasa dan
fotokopi KTP pemberi kuasa. (If the recipient of the funds is other than the parents of the prospective student, it is mandatory to attach a letter of authority along
with the photocopy of the recipient and principal identity card).
 Jika mengikuti Ujian Nasional (UN) tetapi dinyatakan Tidak Lulus UN/SMA (tidak memiliki SKHUN) (If the prospective student has followed the National Exam but
failed to pass the National Exam/Senior High School (does not have the Statement Letter of National Exam Result):
❑ Surat Keterangan Tidak Lulus SMA/Sdrjt (dikarenakan tidak lulus Ujian Nasional SMA /tidak memiliki SHUN) dari Kepala Sekolah (asli) yang mencantumkan
nama siswa, tempat & tanggal lahir, alamat, dan menggunakan kop surat sekolah yang bersangkutan.
(Information of not graduating from Senior High School Letter (due to failure in passing the Senior High School National Exam/doesn’t have the Statement Letter
of National Exam Result) from the Headmaster (original copy) which lists the student’s name, place and date of birth, address, and printed on the school letterhead) ❑
Fotokopi cover buku tabungan orang tua calon mahasiswa. (Photocopy of the bankbook cover of the prospective student’s parent).
❑ Paket Mahasiswa Baru UNIVERSITAS BINA NUSANTARA yang telah diambil (Jaket Almamater, Jas Laboratorium, Binusian Flazz Card, Kartu Briefing, dll)
(New Student’s BINUS UNIVERSITY Package that has been taken (Alma mater Jacket, Lab coat, Binusian Card Flazz, Briefing Card, etc)
❑ Jika penerima dana adalah pihak diluar orang tua calon mahasiswa, maka wajib melampirkan surat kuasa diatas materai, fotokopi KTP penerima kuasa dan
fotokopi KTP pemberi kuasa. (If the recipient of the funds is other than the parents of the prospective student, it is mandatory to attach a letter of authority along
with the photocopy of the recipient and principal identity card).

Mohon dana tersebut di atas ditransfer ke rekening bank sebagai berikut (Please transfer the funds to the following bank account) :
Nomor Rekening (Account Number) : 1020033133544
Nama Pemilik Rekening (Name of Account owner) : Diah Rahmawaty
Bank (Bank) : Mandiri
Cabang (Branch) : Pakubuwono
(Jika rekening yang ditunjuk selain rekening atas nama orang tua, maka wajib melampirkan surat kuasa bermaterai)
(If the designated account is other than the prospective student’s parent, then he/she must attach a letter of authority).

Demikian surat permohonan saya dan dengan terkabulnya permohonan ini berarti saya juga resmi mengundurkan diri sebagai mahasiswa di UNIVERSITAS BINA
NUSANTARA. (Thus, ending my request letter, and I am really thankful for the approval. This also means that I am officially resigning as a student in BINUS UNIVERSITY)

Jakarta, ____________
Hormat saya (Respectfully yours), Diterima oleh (Received by), Diperiksa oleh (Checked by), Didatakan oleh (Encoded by), Menyetujui (Approved by),

( ) (__________) ( ) ( ) ( ) ( )
Mahasiswa Orang Tua Staf Pemasaran Kasubbir LKM Staf LKM Manager SSC/Operations/SLS
(Student) (Parent) (Marketing Staff) (Student Financial Services (LKM Staff) (SSC/Operations/SLS Manager)
Section Head)
……………………………………………………………………………gunting disini (cut here) ……………………..………………..…………….…………

Telah diterima formulir penarikan dana dari (This funds withdrawal request letter has been accepted from):
No. Pendaftaran/NIM/Grade (Registration Number/ID Number/Grade) : 27134353
Nama (Name) : Teuku Mohamad Gennaro Aldi
Total dana yang akan ditarik (Total funds withdrawn) : Rp. 71.150.000

Proses pengembalian dana satu (1) bulan terhitung sejak formulir Penarikan Dana diserahkan ke Admisi.
Refund process period is one (1) month starting from the submission date of funds withdrawal request letter to the Admission).
Jakarta

( )
Catatan (Note):
- Apabila lewat dari tanggal yang ditentukan, dana belum diterima, hubungi 021-29779100 ext 7084 / 7082 (Alam Sutera), 022-20568888 ext 7822 (Bandung), 021-29285598
ext 7918 (Bekasi), 021-5345830 ext 1183 (Kemanggisan), 0341-3036969 ext. 7533 (Malang), 024 - 3569090 ext 7850 (Semarang)
(If the refund has not been accepted after the given due date, please contact 021-29779100 ext 7084 (Alam Sutera), 022-20568888 ext 7822 (Bandung), 021-29285598 ext
7918 (Bekasi), 021-5345830 ext 1183 (Kemanggisan), 0341-3036969 ext. 7533 (Malang), 024 - 3569090 ext 7850 (Semarang)